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Statewide Partners Train Students to Care for Rural Populations

For Michelle Clark-Forsting, MD ’12, MPH, there’s no place like home. She always wanted to be a physician, and many people in and around her hometown of Alma Center, Wisconsin, helped her fulfill that dream.


Living her dream, Michelle Clark-Forsting, MD ’12, MPH, soon will begin caring for patients near her rural Wisconsin hometown.Clark-Forsting, a graduate of the Wisconsin Academy for Rural Medicine (WARM) at the University of Wisconsin School of Medicine and Public Health (SMPH), will begin caring for patients at the Krohn Clinic and Black River Memorial Hospital in November 2015. That’s where she received care as a child and where a physician guided her path by sharing his old medical journals.


After receiving a bachelor’s degree from UW-Eau Claire in 2006, Clark-Forsting hoped she would begin medical school. The fact that she wasn’t accepted at the schools where she applied turned out fortuitous in unexpected ways.


Two years later, she had earned a master of public health degree (MPH) from UW-La Crosse, and the SMPH was launching WARM, which didn’t exist when Clark-Forsting first applied to medical school. Further, she received an email—forwarded by her mother—from Stan Gaynor, the now-retired CEO of Black River Memorial Hospital.


“I read what he described in the email and thought, well, that’s me!” she exclaims, adding that it offered her the chance to develop clinical skills relevant to rural practice.


“I’ve always wanted to go back home and serve the people I live with, work with and play with,” says Clark-Forsting, whose mother, Cindy Clark, is the hospital’s volunteer services manager.


A member of WARM’s second class of students, Clark-Forsting will complete her residency through the SMPH’s Eau Claire/Augusta Family Medicine Residency Program in summer 2015.


Byron Crouse, MD, FAAFP, says Clark-Forsting exemplifies the type of medical student he envisioned when he and others were planning the WARM Program, with the goal of easing the physician shortage in rural areas.


“If I had a stereotype, that would be someone who spent two years at UW-Barron County, went to UW-Eau Claire for a baccalaureate degree, came to Madison for the first two years of medical school through WARM, and completed his or her third and fourth years with one of our academic partners in Marshfield, La Crosse or Green Bay,” describes Crouse, who paints that picture as he recalls visiting UW System campuses to promote WARM.


“Before we started the program, many students eliminated medicine for a career because they thought they had to go to a big city for their undergraduate and medical degrees and on through their residencies. With WARM, that’s not the case,” he says.


WARM students spend their first two years of medical school on the UW-Madison campus with classmates in the MD Program. They complete the required clinical experiences in rural clinics near Madison and relocate to Marshfield, La Crosse or Green Bay for their third and fourth years. All of their required and core clerkships are completed in one of the regional sites, which serve as gateways to rural communities.


“Marshfield Clinic, Gundersen Health System and Aurora BayCare are truly equal partners in this,” Crouse says. “Dozens of physicians who volunteer in the school’s long-running Preceptorship Program play a crucial role in WARM.”


Third-year medical student Hope Villiard examines a pediatric patient at Aurora BayCare in Green Bay.Kimberly Lansing, MD, PhD, a family medicine physician at Gundersen in La Crosse, has been involved with WARM since planning discussions ramped up in 2004; she is the program’s director for western Wisconsin.


Lansing notes, “WARM is rigorous and robust. We know it is solid because these students are getting into residencies without a problem.”


Clark-Forsting, a family medicine physician, is one of the first WARM students to complete clinical rotations in La Crosse. Her classmate and close friend, Abigail Taub, MD ’12, chose a dermatology residency.


Taub shares, “I was initially hesitant about going into dermatology because of the stereotype of cosmetic procedures and big-city medicine. But there is a great need for medical dermatology in rural areas. A patient’s skin—on the outside—is a great clue to what’s happening inside.”


Fifty-eight percent of WARM graduates from 2011 to 2015 entered primary care residencies, including 29 who pursued family medicine programs.


“We know that the needs are greatest for family medicine—probably greater than the other specialties combined—but we heard from our statewide partners that rural areas need physicians in almost every specialty, just far fewer of them,” says Crouse, a family medicine physician who joined the SMPH faculty in 2001 after caring for patients in Spooner, Wisconsin, for many years.


“Because we heard this from our partners as we created the program, we said we would support our students in pursuing the specialties of their choice,” Crouse adds. The WARM Admissions Committee focuses on students who are most likely to practice medicine in a rural community— for instance, those who hail from a rural community, have an interest in family medicine and show a record of community engagement.


“In talking with students, we can quickly pick out those who would thrive in a rural environment,” Crouse explains. “If they are committed to rural practice, we’ll provide them with opportunities to fulfill their dreams.”


David Rebedew, MD ’13, who like Clark-Forsting is a family medicine resident, was so sure he wanted to participate in WARM that he applied only to the SMPH.


“Before medical school, I shadowed a few physicians in small communities, and I really enjoyed the relationships they had with their patients,” Rebedew says. “That level of personal connection with their patients is what I want with my patients.”


However, family medicine wasn’t part of Rebedew’s original plan. With bachelor’s degrees in psychology and neurobiology, he thought he would become a psychiatrist. “Through my medical school rotations, I found that I liked psychiatry, but that I also like emergency medicine, dermatology, neurology and obstetrics,” Rebedew shares. “So I chose family medicine.”


Clark-Forsting and Rebedew are first-generation college students and both chose smaller UW campuses for at least some of their undergraduate work. Rebedew stayed in his hometown for his first two years at UW-Fond du Lac before finishing his bachelor’s degree at UW-Madison. Clark-Forsting’s undergraduate alma mater, UW-Eau Claire, is about 45 miles from where she was raised.


Notably, Nathan Vakharia, MD ’11, was the first WARM graduate to complete a residency and begin caring for patients. Vakharia grew up in McFarland, Wisconsin, 10 miles southeast of Madison, and was drawn to WARM because of his desire to work in an underserved area.


Each WARM student must participate in a community service project. Analise Ruegsegger-Hanneman, MD ’15, (left) helped with the Healthy Lifestyles-Marshfield Area Coalition’s farm-totable project, which encourages local restaurants to use locally sourced food products. Ruegsegger-Hanneman worked with Kayla Ladwig; the chicken in the sandwich is from a local farm.“Having the opportunity to train in a rural environment for my third and fourth years of medical school and for residency deepened my resolve to be a rural general practitioner—in part, because I saw the need in rural areas,” says Vakharia, who moved to far northern Wisconsin in 2014 with his wife and two children after graduating from an SMPH family medicine residency in Baraboo.


After working at Michigan–Wisconsin Family Practice Associates for six months, Vakharia now splits his time between Oconto Falls, Wisconsin, where he is an urgent care and emergency medicine physician, and the upper-peninsula town of Foster City, Michigan, where he established a free clinic. WARM nurtured his independence, he says.


“The Marshfield Clinic staff gave us the autonomy to think independently, and that helped me grow quickly as a lifelong learner,” Vakharia describes. “Learning those skills in medical school was a gift that I will take with me throughout my career.”


Vakharia is not alone in expressing appreciation for the wide-ranging opportunities that WARM provides, especially because of the limited number of medical residents at the Marshfield and La Crosse regional sites and the lack of residents at Aurora BayCare in Green Bay.


“One of the positive aspects about WARM is that medical students gain a lot of handson experiences,” says Analise Ruegsegger-Hanneman, MD ’15, who spent her final two years at the Marshfield site. “You get treated more like a resident sometimes because they don’t have residents for some specialties.” The same holds true for WARM students in La Crosse.


“When we send students to our regional clinics, they often are the only students, and there are no residents, so they get an incredible amount of clinical experience,” says Lansing, an SMPH adjunct associate professor.


Clark-Forsting recalls delivering eight babies on her own as a medical student at Gundersen in La Crosse, which she describes as “pretty amazing for a medical student.” She adds, “I had so many hands-on experiences that I felt extremely wellprepared to enter residency.”


Similarly, for Lucas Kuehn, MD ’15, the potential for many hands-on experiences at Aurora BayCare was a definite draw. Although many people would not describe Green Bay as rural, Kuehn did his primary care rotation in Howards Grove, Wisconsin, population 3,245, and cared for many patients who traveled several hours for care at Aurora BayCare.


“It’s unbelievable what some people have to go through to get health care,” Kuehn says. “That’s one of the things WARM is addressing. We want people to have access to health care closer to where they live.” Kuehn and Clark-Forsting both mention their childhood physicians when asked what drew them to family medicine.


Clark-Forsting shares, “Family medicine is what I always thought medicine was. Clearly, that’s a limited vision—we need specialists, too—but I’ve always wanted to practice primary care.”


Partnership Program Funding Helped Create Wisconsin Academy for Rural Medicine


The Wisconsin Academy for Rural Medicine (WARM) is one aspect of the broader curriculum transformation at the University of Wisconsin School of Medicine and Public Health to incorporate population and public health into its training. As part of its mission to improve health in the state, the Wisconsin Partnership Program has provided significant funding for WARM and the overall curriculum transformation.


WARM was one of the first projects funded through the Partnership Program’s Community-Academic Partnership Fund. Tim Size, executive director of the Rural Wisconsin Health Cooperative (RWHC), led the project with Byron Crouse, MD, FAAFP, serving as the academic partner.


“This grant reflects the true sense of the Wisconsin Idea,” says Size, referring to UW-Madison’s century-old guiding principle that the university should improve people’s lives beyond the classroom. “It’s about the community learning from the school and the school learning from the community.”


The Partnership Program’s one-year, $25,000 grant was followed by a Strategic Planning Grant in 2005 and a Strategic Implementation Grant in 2007. In total, the Partnership Program has provided approximately $872,000 in grant funding to WARM, which is now self-sustaining through tuition and in-kind contributions from its academic partners—Gundersen Health System, Marshfield Clinic and Aurora BayCare.


By Lisa Hildebrand

This article appears in Quarterly.

Date Published: 06/05/2015

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Statewide Partners Train Students to Care for Rural Populations

Last updated: 07/29/2015
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